President of the Public Health Foundation of India (PHFI) and eminent cardiologist Dr. K. Srinath Reddy, who was in the city for the inauguration of the new campus of Indian Institute of Public Health-Hyderabad (IIPH-H), highlights the importance of improving primary health care and public health management with COVID pandemic having exposed the gaps in health system in this exclusive interview.
What has COVID taught us?
There are several lessons COVID has taught us. Unless you have an efficient and equitable public health system functioning reliably in a steady state even without a public health emergency, we will not be able to generate a swift, strong and sustained response. We need to have a strong public health capacity at all levels, right from policy and planning to ground level infrastructure.
Where did we go wrong?
In contact tracing. You have to have trained people and we had entrusted it to the police. We focused in the first few months entirely on tertiary care hospitals, though they were also important for saving lives. We failed to detect early cases when the virus started spreading. If you have a good symptom based surveillance system in primary care, teams can conduct home visits, detect early, test suitably and do a triage to check whether the person needs home care or hospital care. It is essential for vaccination and in dispelling false notions. There was too much emphasis and trust on testing even when asymptomatic and those in pre-symptomatic period were not being tested at that point of time. Our mask mandate came earlier than the West but behind Southeast Asia.
Then, we made a big mistake in hyping up the value of vaccines in preventing transmission when it was evident they stimulate systemic immunity. It means they will fight the virus after it has entered the body and cannot prevent the virus from entering the body.
But, could it not have led to vaccine hesitancy?
No. I think telling the truth is important. If they had said this particular vaccine will prevent severe infection and death, and, it may not prevent you getting infected. For that you use masks and ventilation. Otherwise, we will be giving a handle to anti-vaxxers. For reducing transmission, you need mucosal vaccines, which can prevent the virus from getting into the respiratory mucosa of the nose or the throat.
Why was an effort to make mucosal vaccines not made before intramuscular vaccines?
Mucosal vaccines are difficult to produce and not all trials have been successful. But logic in available vaccines is important too as it could have led to mild infection and likely to discharge fewer viral particles for a shorter period of time. But, it was described as a magic wand to stop transmission completely. It did put some kind of break but the virus has also evolved into immunity evading character, possibly reducing its virulence. Masks, social distancing, and vaccines may have interfered with the virus making it appear more innocuous.
How do we look at the virus adapting quickly?
It is the magic of evolution! If humans are offering resistance either by way of immunity or by way of COVID appropriate behaviour, virus has to increase infectivity and therefore, has to reduce its virulence because it cannot afford to decimate its host populations as it happens at its own risk!
Where do you think we did well?
In building health capacities and responding fast such as testing, masks, personal protection equipment and genomic analysis. There was coordination between the Centre and States but it got challenged in the second wave and we paid a price. We became complacent and created a super highway for Delta variant to spread through various ways. People too wanted their social lives back and it became livelihoods vs risk.
When do we start to prepare for the next pandemic?
It is absolutely important to build trusted public health care systems capable of monitoring and early detection. District and sub-district hospitals should be strengthened with infrastructure and personnel — doctors, nurses, paramedical staff along with PH personnel from medical, social sciences and management fields — as we need multiple expertise teams. I am for opening more medical schools attached to these hospitals to meet the demand. We need to monitor zoonotic diseases and control environmental degradation.